With the approach of adolescence, it is not an uncommon event to experience bleeding from the nose—occasionally at the time of headache, or without evident provocation. Such hemorrhages are analogous to the hemorrhoidal fluxes and the paroxysmal b.moglo binurias of later life. 201 At the age of puberty attacks of articular inflammation that can not be distinguished from acute rheumatism are not unusual. Pur pura sometimes occurs, either with or without the usual visceral or articular disturbances that accompany non-arthritic forms of the disease. It is at this period of life that the tendency to cutaneous disorders which marked the years of infancy again appears, to embit ter the experience of the adolescent patient. Obstinate eczema once more attacks the folds of skin in the flexures of the larger joints, and about the smaller articulations of the hands and feet; often exhibit ing a notable tendency to symmetrical eruption upon the two halves of the body. Acne begins its tedious course upon the temples, nose, cheeks, and shoulders. Sometimes successive attacks of boils appear upon the neck and back. The pustules of acne are frequently of an almost furuncular character, with indurated bases and an indolent course that is marked by passive congestion and a violaceous hue. These patients usually have an acid stomach, constipated bowels, and a tendency to hemorrhoids or to pruritus ani, especially in con nection with the hepatic congestions that are determined by the changeable weather during the spring and autumn of the year.
The pharyngeal mucous membrane at this age exhibits, in a more pronounced form than in early childhood, the granular appear ance that is caused by chronic inflammation of its follicles and other mucous glands. A spasmodic tendency is evident in connection with the bronchial inflammation that occurs. The patient wheezes and coughs with such violence as to suggest the onset of asthma. Hay asthma sometimes occurs during the summer months.
The organs of generation give evidence of participation in the universal over-sensitiveness that is so prominent a feature of the arthritic diathesis. The menstrual flux is irregular in its occur rence, and the young woman suffers with delay in the establishment of the flow; it may be either excessive or scanty, or it may be at tended with severe lumbo-sacral pain. Headache is also a common incident, either before or after the monthly period; and it assumes the usual characteristics of hemicrania.
The intellectual faculties sometimes share in the disturbance at this time; the patient is irritable, peevish, and depressed. Young men display a similar exaggeration of the emotions in association with an inordinate irritability that takes the form of prolonged and uncomfortable erections, with nocturnal emissions. Herpetic erup tions sometimes appear upon the glans and prepuce. The urethra is readily inflamed, so that infection produces most painful and persis tent forms of gonorrhlea. Even without infection, attacks of uretliri
tis sometimes exhibit a degree of severity that completely rivals the genuine venereal disease. Such forms of urethritis are liable to frequent relapses, and they often subside into a chronic gleet that is almost incurable. This state of things is usually accompanied by an over-acid state of the urine which is probably one of the principal causes of the persistence of the inflammation. In arthritic children and adolescents, the act of micturition is frequently attended by severe cutting pain along the urethra, even when no inflammation is present. This is due to the action of acid urine upon an inordinately sensitive mucous membrane. So hypeiwsthetic are certain individ uals that a few glasses of beer, champagne, or cider may suffice to de termine a urethral crisis, especially if accompanied by venereal ex citement of any sort. The urine, in such cases, frequently deposits a sediment of urates or of uric acid, on cooling. This, however, should not be deemed a symptom of importance, unless associated with other evidences of the arthritic diathesis, or unless the incident is often repeated.
During the period of adolescence, headache is frequently experi enced. Any little disorder of the digestive organs is apt to be ac companied by an attack of migraine; and in many instances it recurs without any apparent cause. Sometimes it assumes the character of dull, ill-defined feeling of weight and pressure within the cranium, rendering the patient temporarily incapable of mental application. Sometimes the pain assumes a more distinctly neuralgic character. The eye may become intensely painful, though exhibiting no evidence of other disorder. Often the sufferer experiences violent shocks of shooting pain that dart like a flash from one part of the head to another, constituting a local manifestation of a general tendency to lancinating pains in other organs and parts of the body—quite like what is so frequently experienced in tabes dorsalis.
Digestive disorders, which were usually brief and transient in childhood, now become more serious than formerly. The arthritic subject usually enjoys a good appetite, and is liable to overload his stomach. Fermentation, acid eructations, and accumulation of gas in the alimentary canal, now occur. The stomach becomes distended —it may finally be dilated—and there is a constant feeling of uneasi ness in the epigastric region. The act of eating usually adds to the distress, and may be followed by painful irradiations into the hypo chondria and interscapular space. The appetite may be extinguished, or it may exhibit great exaggeration and perversion. Young women manifest a craving for all sorts of indigestible and inedible articles. Often there is a longing for acids, pickles, spices, and their like. Sometimes, especially when the stomach is empty, there is great abdominal pain, accompanied by feelings of intense exhaustion.